Hi, this is Sagar Wagle, one of the musculoskeletal radiology fellows at Stanford University. We have a case of a 24 year old soccer player with painful pop in the left lateral foot during a game. There's a concern for fracture. A radiograph shows a fracture at the base of the fifth metatarsal. At the base of the fifth metatarsal, we have the peroneus brevis tendon and the lateral quarter of the plantar fascia attached. Let's learn about different fracture types of the proximal fifth metatarsal. The first fracture is pseudo Jones fracture. It is an avulsion type fracture due to avulsion from the peroneus brevis tendon. This involves the articular surface of the cuboid with the fifth metatarsal and this area has good vascular supply, so it heals well. Jones fracture does not involve the fifth torso metatarsal articulation, but it involves the intermetatarsal articulation between the proximal fourth and fifth metatarsal. Jones fracture is in vascular watershed region, so this fracture does not heal well. Stress fracture occurs slightly more distal to the intermetatarsal articulation and stress fracture also does not heal well. Here we have a case of a 19 year old soccer player with chronic fifth metatarsal pain. This fracture does not involve the torso metatarsal articulation, so this is not an avulsion fracture. This is slightly distal to the intermetatarsal articulation and also based on the history, this is a stress fracture and this patient was treated surgically. We can see that the fracture has gotten better. There's a lucency here. This is not a fracture. This is articulation between the torso and the fourth metatarsal bone. We have a case of a 63 year old woman who rolled her ankle. We can see that this fracture does not involve the torso metatarsal articulation. This seems to involve the intermetatarsal articulation, so this is an example of Jones fracture. At three month follow-up, the fracture has gotten wider and the patient has persistent pain, so this fracture did not heal well. We have a 20 year old woman with foot pain. Here, this bony fragment that we see is not a fracture fragment, but this is a normal apophysis, which is a secondary ossification center. Fractures in proximal fifth metatarsal are oriented more horizontally. This is vertical. This fragment is also well-cordicated, so this is not a fracture fragment. Let's go back to our original case. Let's go back to our original case. We have an avulsion fracture of the fifth metatarsal base because this involves the torso metatarsal articulation. This patient also had avulsion fracture in the other foot and looking at bone scan, which is a type of nuclear medicine study, we see increased radiotracer uptake at the fifth metatarsal base corresponding with our avulsion fractures. There are no widely accepted guidelines on whether or not or when to get follow-up radiographs for proximal fifth metatarsal fractures. Given that the vascular supply could be compromised, some clinicians choose to get follow-up radiographs. Thank you for watching the video.

3rd Edition, CASE 18

3rd Edition

Foot

proximal fifth metatarsal

avulsion fracture

Jones fracture

stress fracture

healing trajectories